Healthcare in China
29 November 2017
Our directors, David and Deanna Coles, recently had the pleasure of visiting China to present some lectures and workshops on Hand Therapy and Orthopaedic medicines. During the visits, they gleaned many insights into the eastern perspective of healthcare and physical therapies.This month, Dee shares some of her reflections regarding the Chinese healthcare system.
In November, Dave and I had the opportunity to present some guest lectures at private clinics across China. During this program, we also met with traditional medicine therapists, Chinese herbalists and hospital clinicians.
Healthcare in China has many similarities to Australian care. Residents who get sick, will visit a general practitioner or a hospital. They have a home visit service, usually staffed by nurses and they have a similar therapist referral system for physios and occupational therapists. There are however, some notable differences.
China is home to over 1.4 billion people. The size of their healthcare system is staggering. According to the World health Organisation in 2016 there were over 29 000 hospitals and innumerable health clinics, therapy rooms, low level private hospitals and other grassroot care clinics. In contrast, Australia, has 701 public and 630 private hospitals. The sheer size of the hospitals are daunting but maintain an impressive organised chaos. Upon visiting, it seemed that you only had to cross a road to find another hospital however we soon realised that not all are created equal.
China classifies their hospitals into 3 levels or tiers, with level 3 hospitals best reflecting Australian hospital standards. These hospitals will have consultant led doctor teams, a good rehabilitation program, diagnostic equipment and usually research programs. In contrast, level 1 hospitals could be staffed with residents and unskilled support workers instead of nurses and therapists. This leads to a huge burden on the higher tier hospitals with patient wait times sometimes 7 hours long just to be registered. While we watched a huge queue applying for care, our guide informed us that usually it is the patient that states and decides the department that they need to visit. There are no nurse assessment stations and patients will be triaged by the corresponding department of their request. This leads to large patient transfers between specialities until the right area is decided upon.
Another significant difference to the Australian healthcare system is the under-utilisation of GP clinics. Many Chinese people will visit the hospital even for minor complaints, placing greater trust in hospital trained doctors rather than the smaller, less regulated clinics. We were informed that blood sugar monitoring, injuries requiring dressings, high fevers, among others things would all be routinely treated within the hospital system. Despite this, physician numbers in hospitals are huge compared to nurses, with most hospitals having many more trained doctors than other support staff. It is common for all orders to be issued by doctors with no therapist led programs or multidisciplinary teams. We spoke to one orthopod whom said he routinely works 12-14 hour days, 6 days per week and sees his patients for a maximum of 7 minutes, including the initial consultation. However the drive of all these doctors to attain credentialed levels created an immense boiling pot of ideas and expertise.
Each department within the hospital is required to work autonomously and is required to raise its own funding to meet the government deficit. This is done through medication prescriptions, private funding from benefactors for research, registration and treatment fees. This has an impact on the therapy care as surgery and rehabilitation are in separate departments and physicians are loathe to lose a patients’ fees through referring to another department. Our guide informed us that many patients do not have to pay anything to see a specialist or sometimes a minimal fee ($10) however to get on a specialist waiting list you may be able to obtain the fast track phone number for a ‘couple of hundred extra’.
This opens up a huge area of privatised health in China. Private hospitals currently account for 53% of all hospital beds in China. Residents currently pay a large amount of wages into private health fund equivalents which allows them access to a greater number of services. These services may include physiotherapy, OT, traditional Chinese medicine, speech pathology, private hospital care and many other care options. Many western style therapy clinics are available through private health with very experienced staff (often trained in Australia). We were informed that the most expensive funds will also include overseas care, primarily at sister hospitals in the United States.
Significantly, preventative health or primary care is also limited due to the vast number of citizens. It is also significantly more expensive, often not covered by insurance, and is without the large nationwide programs that Australia maintains. This coupled with the huge aging population and increased burden of air pollution, the healthcare system is finding it increasingly challenging to transition to a chronic disease care model. This service is widely performed by Traditional Chinese Medicine clinics (TCMs).
Traditional Chinese Medicine
Within China’s healthcare system ‘eastern’ and ‘western’ medicine sit side by side, often within the same clinics and departments. As China removed many international boundaries, these traditional techniques came into question. Today, clinics, are considered as equally valid to western medicine and are considered on par with the evidence based western medicine. While visiting many of these clinics we were astounded at the unusual methods of finding and treating disease. Pulse diagnosis (where a TCM doctor can tell what’s wrong with you by touching your wrist) and the pungent aroma of herbal medicine packs filled us with concern as evidence based medicine advocates. However the intricate knowledge of anatomy and the ability to treat a person as a whole system, left us with lots of questions. We saw vomiting, blood noses, chronic conditions and a possible wrist fracture all being treated by the clinicians.
Rehabilitation medicine is widely practiced within China and is one of the standard departments in every hospital. It is extremely organised and an essential part of patient care. Specifically Physiotherapy and Occupational Therapy fall under this banner however varying levels of programs exist within this area. Physical therapy is not considered a stand alone specialty and until as recent as 2005 support staff would not necessarily be university trained. Traditionally, therapists would glean knowledge from other support staff or senior rehabilitation doctors. More recently there has been a push for higher qualifications, with some universities offering new courses. Part of this lack of emphasis is due to societies view of illness, where sick people need to rest and not actively participate in physical programs. This is in contrast to their long history of valuing gentle exercise for the older population. Due to the way funding is apportioned (see Revenue raising above), there is also a lack of consultation with surgeons and therapists, specially leading to delayed or no treatment. Again, the private sector is changing this and we visited clinics where surgeons and therapists worked closely together. Therapists were very confident that within the next 5 years this will be a fast developing and respected career.
Next month we will discuss our experiences with hand therapy rehabilitation in more detail.